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Word of Appreciation
Updated: 02/23/2011

Request Information about Personal Oral Health Consulting by Telephone

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Consulting includes:

  • Telephone consulting on any oral health questions or concerns
  • Consulting session includes Sheila's e-book Your Mouth Could Be Killing You!
  • Rates are $30 for each 20 minute increment.

Please complete this form. Items marked with * below are required. Thank you so much!

Contact Information

How can Mama Gums contact you? 

First name*:

Last name*:

Daytime phone*:

Evening phone*:

Fax:

Email address*:

Street address:

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Best day/date to contact you*:

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How did you learn about Mama Gums?
Subject Information
Please describe the issues you wish to discuss with Mama Gums*
What specific problems are you experiencing (check as many as apply)?
Gums are tender, swollen, painful, or itchy
Pus oozing from gums
Gums bleed when brushing teeth, flossing, or using a toothpick
Gums are receding (pulling away from teeth)
Teeth seem loose
Spaces developing between teeth
Teeth seem to be moving
Changes in fit of partial denture
Constant bad breath
Changes in your bite
Disclaimer & Privacy Acceptance
*I have read, understood, and agree to Mama Gums privacy statement and disclaimer. (Please click the links to view these items.)
      

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Personal Oral Health Consultant/Coach

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